EMT I-Tech Operational PlanComponents
911 / Interfacility / BothPhase-in: Y / NNon-Transporting: Y / NTactical EMS: Y / N
Program Components
/EMS Section Response or Approval
/Submitting Agency Reply
I. Initial Tasks to be Completed
- Completed feasibility study submitted and approved by DHS-EMS
- Provide documentation that a community meeting was held includingany concerns that were identified.
II. Operations (staffing, response, infection control, protocols, policies and procedures)
- Complete Operational Plan form F-47463.
- Name of service
- Current service license level
- Service license level being requested
- Name of Service Director
- Name of Medical Director
- Provide a description of how the provider will use First Responders and/or EMT’s (of all levels) in the system.
- Identify the hospital that will provide your day to day Medical Control.
- Provide a general description of the population, community characteristics and map of the primary service area.
- Provide a statement indicating the provider understands the requirement to assure 24/7 coverage for any 911 response.
- Provide a statement that the service provider will comply with staffing requirements identified in Administrative Rule and State Statute
- Provide copies of written mutual aid and backup agreements with other ambulance services in the area.
- Identify the Regional Trauma Advisory Council (RTAC) that the service has chosen for membership.
- Provide evidence of local commitment to this emergency medical service program to include letters of endorsement from local and regional medical, governmental and emergency medical services agencies and authorities.
- Submit protocols, signed and approved by the medical director, that identify use of:
- Specific medications allowed within the scope of practice
- Specific equipment allowed within the scope of practice
- Skills and procedures
DHS 110.35(2)(a)
- Provide a formulary list of medications
- Provide a list of optional skills and procedures intended to be used within your scope of practice.
- Proof of professional liability, medical malpractice and vehicle insurance, as appropriate.
- Provide copies of the service operational policies which at a minimum include the following:
- Response Cancellation
- Use of Lights & Sirens
- Dispatch and Response
- Refusal of Care
- Destination Determination
- Emergency Vehicle Operation and Driver Safety Training
III. Infection Control
- Provide a statement indicating your service has an Infection control plan and provides annual training according to OSHA 29 CFR 1910.1030 for Blood borne pathogens and 29 CFR 1910.134 Hepa mask fitting.
- Identify date that your Exposure Control Plan was last reviewed and updated.
- Identify date of last training on your service’s Exposure Control Plan.
IV. Communications/Dispatch
- Provide a description of the communication system between medical control and the EMS unit.
- Does each ambulance owned and operated by this service have two-way radio equipment operating on the 155.340 and 155.400 Mhz?
- Is two-way communications available and operational from the patients’ side?
- Describe how calls are dispatched and answered.
- Describe local dispatch policies and procedures or insert a copy of these policies.
- Who does the dispatching?
- Are dispatchers medically trained?
- Do dispatchers provide pre-arrival instructions?
V. Education and Training/Competency
- Identify the Training Center with which the service is affiliated.
- Describe the methods by which continuing education and continuing competency of personnel will be assured. (Provide type of education, testing, frequency, instructor, etc.)
- Describe who will assure personnel competency?
VI. Quality Assurance
- Submit a plan describing how the service will provide quality assurance and improvement.
- Provide copies of Policies and Procedures to be used in Medical Control implementation & evaluation of the QA program.
- Provide a description of the benchmarks to be used by the service to assure competency of all providers.
VII. Data Collection
- Provide a statement that the service agrees to submit data to WARDS.
- Identify the software vendor if the service is using a third-party software to collect data.
IF REQUESTING 12-MONTH PHASE-IN OF FULL-TIME COVERAGE
Service provider wanting to provide coverage over a phase-in period shall submit an operational plan to the department that includes all of the elements under DHS 110.34 &110.35 in addition to the following:- Service provider must show evidence of hardship, which requires request for 12-month phase in.
- A description, in detail, of why the phase-in period is necessary, how the phase-in will be accomplished and the specific date, not to exceed 12 months from the initiation of coverage until full-time coverage will be achieved.
- A description of how quality assurance and skill proficiency will be evaluated during the phase-in period.
- Provide a statement that during the phase-in period, all requirements under WI Statute 256 and DHS 110shall be met except for the requirement to provide the higher level of coverage 24/7.
- Provide a statement that the service provider that does not achieve full-time coverage within the approved phase-in period, 12-months maximum, shall cease providing the higher level of coverage and shall revert back to the previous level the service provided.
IF YOU ARE REQUESTING INTERFACILITY TRANSPORTS
Service provider wanting to provide interfacility transport coverage shall submit an operational plan to the department that includes all of the elements under DHS 110.34 &110.35 in addition to the following:
- Describes how interfacility transport services will be provided.
- Provide a statement indicating the understanding that providing interfacility transports will not interrupt 911 emergency responses.
- Describe the crew configuration and personnel to be used on specific type of patient transfers based upon the patient’s condition.
- Provide a statement assuringthat Mutual Aid agreements will not be used to cover the primary service area while providing Interfacility Transports.
- If the service also provides 9-1-1 coverage confirm a minimum one ambulance for 9-1-1 emergency response and one ambulance for interfacility transports. Unless the service provider has a coverage agreement with a neighboring service provider that will provide one 9-1-1 ambulance for each primary service area.
IF YOU ARE REQUESTING SPECIAL EVENT COVERAGE
This section covers prehospital service provided at a specific site for the duration of a temporary event, which is outside the ambulance service provider’s primary service area or at a higher license level within the provider’s primary service area.If the special event coverage is at a higher level of care than the service is currently licensed to provide, a specific operational plan for special events shall be submitted and approved that includes all the elements under DHS 110.34 &110.35 that differ from the existing approved plan.
- Describe how the special event differs from the existing approved operational plan.
- Describe how the ambulance service applying for special event coverage will work in conjunction with the primary emergency response ambulance service in the area.
- Provide letters of support from the primary ambulance service provider indicating they are aware of and agree to allow the special event ambulance provider to operate within the primary services area.
- Provide a letter from the Medical Director responsible for services during the special event indicating acknowledgement of responsibilities.
INTERMEDIATE TECHNICIAN SPECIFIC REQUIREMENTS
shall submit an operational plan to the department that includes all of the elements under DHS 110.34 &110.35 in addition to the following:
- Identify the number of ambulances that will provide 911 coverage 24/7.
- Provide evidence that all ambulances to be used by the service have been inspected within the last 2 years (6 months for newly acquired vehicles) and are in compliance with Trans 309 with all required paramedic equipment. (State Ambulance Inspector 608-516-6562).
Plan Approved By:
Date:
Entered into E-Licensing:
Bureau Notification:
1
Revised: Nov 2011Page